- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $4,365.16 / $10,964.78
| Facility | | $831.76 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $457.09 / $1,047.13
| Professional | | $363.08 | $457.09 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,762.47 / $14,791.08
| Facility | | $2,754.23 | $7,762.47 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $1,023.29
| Professional | | $371.54 | $562.34 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $3,715.35
| Facility | | $676.08 | $1,479.11 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $645.65 / $1,380.38
| Professional | | $407.38 | $645.65 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,265.80 / $10,000.00
| Facility | | $1,548.82 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $512.86 / $954.99
| Professional | | $363.08 | $512.86 | $954.99 |